Herbert Snow’s attempt to turn the tide

One of the reasons why circumcision remained a minority practice in Britain is that it never commanded the unanimous assent of the medical profession and, unlike in the USA, there were always vocal critics from within the medical fraternity itself. One of the earliest of these was Herbert Snow, who wrote a short book against the rising tide as early as 1890, and which he called The barbarity of circumcision as a remedy for congenital abnormality.

The context

It is not possible to hail Snow’s text as a model for today’s critics of routine circumcision, much less as a source of reliable anthropological or biological knowledge; what is interesting is not that Snow was ahead of his time, but the extent to which he was bound by the limited and erroneous knowledge of his place and period. The most serious instance of this is his acceptance of the theory of congenital phimosis and consequent belief that the infant’s foreskin should be mobile and retractable within a few days of birth. His argument was not that this theory was wrong, but that circumcision was an inhumane and barbaric way to deal with the problem; the right way was by dilation of the foreskin. He thus became one of the founders of the “dilatation vs circumcision” debate, which dominated the discussion of the issue until Douglas Gairdner disproved the theory of congenital phimosis in 1949. Snow’s discussion of the historical evolution of circumcision as a religious rite is less off the track, but even there he was often misled by the limitations of the anthropological research available to him.

Snow’s argument

In his booklet, The barbarity of circumcision as a remedy for congenital abnormality, Snow’s stated aim was “the abolition of an antiquated practice involving the infliction of very considerable suffering upon helpless infants; and sanctioned, on very questionable grounds, by men of eminent authority”. This statement concisely set out the terms of his opposition: circumcision was an antiquated religious custom, not a modern medical therapy; it meant suffering and harm to a class of patient who had not given consent; and the grounds advanced to justify it were spurious. He also implied that the advance of circumcision was an effect of the authority of its promoters, not of the quality of their scientific reasoning. On the first point, Snow rejected hygienic explanations for the origin of ritual circumcision and accepted the argument of anthropologists that it was a sacrifice intended for a deity which obviously required appeasement, and probably an attenuated form of what had once been the sacrifice of something yet more precious, such as the entire genitalia or living children. He took the view that the tribes who practised circumcision were barbarians whose customs did not warrant emulation by modern Britons.

On the second point Snow made the reasonable suggestion that “no sane man who possessed the advantages of a sound and entire prepuce would willingly sacrifice it without just and sufficient cause being shown”. He described circumcision as

the abstraction of a structure, not indeed of paramount importance to the organism, but obviously evolved by Nature for wise ends as a protective covering. Were there no necessity for its presence it would not occur; and without overwhelming evidence that such mutilation is unavoidable and beneficial, it must be held ethically criminal thus to lay rough hands upon a perfectly normal organ.

Snow then argued that the four advantages claimed by the proponents of circumcision did not stand up to scrutiny. He dismissed “enhanced local cleanliness” as trivial and irrelevant in modern conditions, commenting that nobody advocated similar tactics like shaving the head or pulling out the toenails. On the argument for greater chastity and “preclusion of immoral personal habits”, he agreed about the importance of chastity but considered the evidence to be inconclusive; he countered that plenty of Jewish and other circumcised men were known to masturbate, and made the desperate and improbable claim that early removal of the prepuce encouraged infantile fondling. On the argument for protection from venereal disease, he found the case “not proven”, and he pointed out that even Hutchinson’s statistics showed that (circumcised) Jews were more prone to gonorrhoea. On the claim for protection against cancer of the penis, Snow replied that this was a rare disease of adults, more likely caused by phimosis and poor hygiene than the foreskin per se.

Disadvantages of circumcision

Turning to the offensive, Snow then listed the “disadvantages and dangers of circumcision”, and devoted several pages to a discussion of what are now called “risks and complications”: the most common injuries inflicted during the procedure and some of the longer term side effects. He commented that the traditional Jewish practice of metsitsah (the sucking of the penis following the cutting of the foreskin) had been largely discontinued among modern communities because of its role in transmitting syphilis and tuberculosis. He also warned that infection, haemorrhage, ulceration and damage to glans, meatus and shaft were regular occurrences when circumcision was performed in surgical settings, but his case lacked force because he could not produce figures: nobody was recording instances even of immediate injury and death, let alone the longer term problems (such as excessive tissue loss) which might not become apparent until puberty brought the penis to its full size. If official statistics in the 1940s showed 16 deaths each year from surgical complications, it seems likely that the number of fatalities before antibiotics must have been considerably higher. Snow was rare among medical commentators in showing some regard for the boy being operated on as a subject with his own feelings and opinions, rather than a mere object at the mercy of guardians and doctors:

An American operator … speaks of the difficulty of keeping children’s knees out of the way after removal of the prepuce, and of the consequent torture to them. Even after healing, contact with flannel napkins and other clothing must long be very painful. There can be little doubt what would be the verdict – could they only give it utterance – upon the immediate results of the operation in question, returned by these inarticulate (if far from mute) victims of hygienic orthodoxy.

If Snow was unusual in showing scruples about consent, he was even more radical in admitting that “an objection to circumcision of wholly sentimental character [is] not the less worthy of practical consideration”. Why shouldn’t boys be emotional about their penis?

Its reception

The barbarity of circumcision was reviewed cautiously by the British Medical Journal, which had reservations about Snow’s sweeping rejection of circumcision; and sympathetically by the Lancet, which was “inclined to endorse most of what he says”. It agreed that circumcision was a relic of primitive man, pointing out that the peoples which still practised it were “many of the least civilized peoples on the face of the globe”. More significantly, it accepted Snow’s argument that an operation was rarely necessary “for the relief of congenital phimosis”, and it actually proposed that “the prepuce is not the valueless or mischievous appendage that some would have us believe”; although “non-separation of the prepuce from the glans penis is constantly mistaken for phimosis”, only genuine cases of the latter required operative treatment. The reviewer did not go so far as to suggest that an adherent prepuce needed to treatment at all, but he supported Snow’s view that “forcible retraction” and its “daily repetition for a short time” was all that was required. It is thus clear that Snow was not an isolated voice, but equally apparent that the misconceptions about genital anatomy and preputial development which had originally led to the craze for widespread circumcision were very deeply ingrained.

The full text of the reviews in the BMJ and the Lancet are below.

Limitations of Snow’s argument

The effectiveness of Snow’s intervention was limited by two serious weaknesses. First, he accepted the current medical wisdom that the adherent and non-retractable foreskin was indeed a pathological defect which required speedy correction. he went so far as to write that “a perfectly healthy condition of the male generative organs is compatible only with perfect mobility of the prepuce over the glans”, and further conceded that it was “universally agreed” that “the adhesions between the prepuce and the glans can nearly always be broken down … during the first few weeks after birth”. Where he differed from most of his colleagues was in his insistence that this could be achieved by manipulation and dressing, rather than amputation. It was, however, very hard to defend the foreskin by thus conceding the major complaint of its enemies, for it was this very “phimosis” which formed the basis of their charge that it led to childhood masturbation, nervous diseases and increased susceptibility to syphilis and cancer. Snow argued that all these risks could be managed conservatively, but his methods were a lot of bother, and it is little wonder that many doctors and parents preferred the quick snip.

Secondly, for all the depth of his conviction that possession of one’s foreskin was advantageous, Snow was hard-pressed to articulate what those advantages were. The best he could do was cite Dr Willard (from Keating’s Cyclopaedia of diseases of children) that its functions were “to protect the head of the organ during the years when the penis is but a portion of the urinary apparatus; and later, by its friction over the sensitive corona, to enhance the ejaculatory orgasm”. He actually rejected Willard’s largely correct echo of Aristotle’s master-piece, that foreskin and glans worked in tandem to generate sexual sensation (though even he emphasised the final orgasm at the expense of the pleasures of getting there). Snow replied with the ignorant majority that “since the prepuce is completely retracted during coition … no friction over the corona can well take place”. But even if this were true (and there is obviously much variation from one individual to another), the foreskin would still increase sensation by the mere fact that its nerve-rich surfaces were now redeployed along the shaft of the erect penis. All Snow was left with was the rather lame protestation that the foreskin was necessary to protect the glans – a plea which fell easy prey to the sallies of Clifford and Remondino, who simply countered that the protection needed by naked savages leaping over thornbushes was no longer essential for civilized men wearing underpants. Without appreciation of the complex innervation and physiological role of the foreskin, and thus awareness that it had significant value in its own right, it was difficult to argue effectively against its dismissal as a redundant scrap of skin.

This title page is taken from an interesting copy of Snow’s book. It shows that this copy was owned by Ernest Hart, editor of the British Medical Journal, and that he presented it to the library of the British Medical Association. It may well be the very copy that Snow sent for review to the journal, in which case it is also possible that Hart himself was the reviewer.

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Reviews of The barbarity of circumcision

The Lancet

The barbarity of circumcision as a remedy for congenital abnormality, by Herbert Snow, MD, Surgeon to the Cancer Hospital

We must confess to sympathy with the main contention of this brochure, which is that circumcision is a relic of barbarism which has survived in certain races because elevated into a religious rite. Its origin in barbarism is seen by its being practised by many of the least civilized peoples on the face of the globe. But it is the surgical argument which is of most interest, and while we cannot go with Dr Snow to the extreme to which the zeal of the advocate has led him, we are inclined to endorse most of what he says. The prepuce is not the valueless or mischievous appendage that some would represent it to be, nor its removal so entirely harmless as some would have us believe. The great fact, however, on which we would lay stress is the rarity of any necessity for circumcision for the relief of congenital phimosis. Non-separation of the prepuce from the glans penis is constantly mistaken for phimosis, and while the latter requires some kind of operative treatment, the former never does in infant and little boys. The forcible retraction of the prepuce (very slight force is really needed), and the daily repetition of this for a short time, brings about in a perfectly harmless and only slightly painful manner a better result than the operation of circumcision effects.

The Lancet, 20 June 1891, p. 1386

British Medical Journal

Dr Snow has a strong objection to circumcision as a remedy for congenital phimosis, and brings forward facts and arguments in this little book in order to prove that the operation, whilst causing much suffering to helpless children, is as a rule quite unnecessary. Although, as is acknowledged in the preface, no one could expect without presumption to abolish this practice altogether, it is probable that many of those who peruse this book will be induced to question the propriety of resorting very frequently to circumcision in the treatment of certain abnormal conditions of the prepuce.

The first chapter is devoted to an historical sketch of circumcision as a religious rite. Dr Snow’s work is too small for a satisfactory discussion of so large a subject, but he has collected many interesting facts, and presents good grounds for the view he holds that circumcision , as regularly practised by very numerous races of diverse origin, is essentially a sacrificial and religious act, and has no title to any hygienic character or purpose.

In a subsequent section there is a full discussion of the arguments in favour of the removal of the prepuce in cases of supposed congenital abnormality. The author holds that the operation does not conduce to local cleanliness in after-life, or to greater chastity and, moreover, that it does not serve to protect the subject from venereal disease or render him less prone to cancer. In many cases, it is asserted, death has been caused by circumcision, and the operation in most instances entails as an immediate result much suffering, and as a remote result contraction of the meatus urinarius. Even in cases of acquired phimosis and in adult subjects circumcision, it seems, is not free from risk. Indeed, Dr Snow would reserve the operation for some few exceptional cases of chronic acquired phimosis.

With regard to the congenital form, he holds that the common-sense and most satisfactory treatment is dilatation, associated in complicated cases with limited incisions. With the results of such treatment the author states that he is entirely satisfied. There can be little doubt, we think, that circumcision has frequently been performed in cases in which [a] careful and prolonged bloodless plan of treatment might have effected a cure. Dilatation, however, is by no means a novel plan of treatment, and, as Dr Snow tells us, it “must have been repeatedly resorted to by many practitioners of the past.” many and varied forms of instruments have been devised for carrying out such treatment, some of which are described in this book. This fact, together with that of the advocacy of circumcision in cases of congenital phimosis by many very cautious and experienced surgeons, would seem to us to suggest that the dilatation method may not be invariably satisfactory, and that a certain number of cases may remain in which operative treatment will be found necessary.